Method for treating ocular Demodex

ABSTRACT

The present invention relates to a method for treating a disorder chosen from ocular  Demodex, Demodex -induced blepharitis, rosacea, acne, and meibomian gland dysfunction in a patient in need thereof, comprising administering to the patient a compositions comprising a therapeutically effective amount of a substance chosen from at least one of an isoprenoidal essential oil such as Tea Tree Oil; Terpinen-4-ol; (+)-Carvone; alpha-Terpineol; Cardinene; d-Carvone; 1-Carvone; gamma-Terpinene; alpha-Terpinene; 1,8-Cineole; alpha-Terpineol; para-Ci mene; alpha-Pinene; Limonene; (R)-(+)-Limonene; alpha-Thugene; Eucalyptol; (+)-Ledene; Cuminic Aldehyde; and Myrcene; the administration comprising contacting or scrubbing an affected area of skin or hair, or eyelid margin and lashes of the patient with the composition; also disclosed are a method for treating mange and mite infestations on a mammalian animal; and kits for in-office and at home treatments of the disorders.

RELATED APPLICATION

This application is a continuation of U.S. patent application Ser. No.13/181,767 filed on Jul. 13, 2011, now issued as U.S. Pat. No. 8,440,240on May 14, 2013, which is a division of U.S. patent application Ser. No.11/911,956 filed on Jul. 23, 2008, which is a national stage entry ofPCT Patent Application No. PCT/US2006/16601 filed on Apr. 28, 2006,which claims priority from U.S. Provisional Application No. 60/676,692filed on Apr. 30, 2005, all of which are incorporated herein byreference in their entireties.

BACKGROUND OF THE INVENTION

Blepharitis, an inflammation of the edge of the eyelid, is a commonclinical problem. Blepharitis occurs as an ulcerous (staph) form ornonulcerous (seborrheic) form, or as a combination of both forms. Mixedblepharitis is seborrheic with associated staph. Patients who sufferfrom blepharitis as a result of an ocular demodex infestation oftenpresent with a number of symptoms such as a foreign body sensation,redness and itching. The symptoms can become severe enough that thepatient may require surgery to achieve relief. However, even invasivetreatments such as surgery often result in no significant improvement,and/or a recurrence of the demodex infestation.

Demodex mites, Class Arachnid and Order Acarina, are elongatedectoparasites. Among a wide range of reported species, only two, demodexfolliculorum (D. folliculorum) and demodex brevis (D. brevis), are foundon the human body surface. Adult D. folliculorum is commonly found insmall hair follicles. D. brevis burrows deeper into the eyelashsebaceous gland and the meibomian gland. Both demodex species oftencoexist at the same skin area and tend to gather in the face, cheeks,the forehead, the nose, and the external ear tract, where active sebumexcretion favors their habitat and breeding.

Acarine arachnids such as the demodex mite, demodex folliculorum, alsocan infest mammalian quadrupeds, in particular domestic animals,especially dogs, causing demodetic mange. The demodex mite burrows intohair follicles and sebaceous glands of the animal, the mite oftencausing severe dermatitis, infection, and discomfort. Demodetic mange,particularly in dogs, presents a difficult clinical problem forveterinarians, as it can involve the face and the entire body of theanimal in some cases. Existing treatments can be expensive and are notalways effective, with the result that affected animals are sometimeseuthanized.

Mange can also be caused by the burrowing parasitic mites Sarcoptes,which causes scabies, and Chorioptes. The Cheyletiella mite causes acondition known as “walking dandruff” In cats, notoedric mange is aburrowing mite infestation that is difficult to treat.

In general, parasitic mites such as those causing mange aretransmissible to humans.

Generally, demodex is currently treated with both systemic and topicaladministration of parasiticides. For example, ocular demodex in humansis treated by daily practice of eyelid margin scrub with diluted shampooalone or combined with 1% mercury oxide ointment, 2% metronidazoles gelor Pilocarpine gel at the base of the eye lashes at the night time.Ophthalmic reports demonstrated a dramatic decrease in the demodex countobserved during the follow-up examination.

However, to date, no report has demonstrated that these treatmentsactually kill demodex in vitro and no therapeutic agent has completelyeradicated ocular demodex within one month. Indeed, recentinvestigations revealed that ocular demodex persists in 50% of patientseven after one year of lid scrub with ordinary, diluted shampoo alone orcombined with 1% mercury oxide ointment, 2% metronidazoles gel orPilocarpine gel.

Rosacea is a chronic dermatological disease that affects the skin,usually the face, and sometimes the eyes. Only rarely are other parts ofthe upper body affected. One type of rosacea, inflammatory rosacea,causes persistent redness and pink bumps referred to as papules, andpustules on the skin. Eye inflammation also may occur, with symptomsoften including sensitivity to light, blurred or otherwise impairedvision, redness, dryness, itching, burning, tearing, and the sensationof having grit or sand in the eye. The eyelids may become inflamed andswollen. “Rosacea”, as the term is used herein, refers to both “rosaceaof the skin” and to “ocular rosacea”.

In an advanced stage of rosacea, inflammation of the eye is moreapparent, and the skin thickens and becomes a deep shade of red. Rosaceais difficult to treat. Current treatments include oral antibiotics,e.g., tetracycline or doxycycline. If infections of the eyelids develop,physicians may recommend scrubbing the eyelids with diluted babyshampoo. Steroid eye drops may be prescribed in the case of severeinfection.

Acne, including acne vulgaris and acne rosacea, is yet another chronicdermatological condition that is difficult to treat. Over-the-counterproducts for treatment of acne, including benzoyl peroxide and aluminiumchlorhydroxide/sulphur can help reduce, but not cure acne. Prescriptiontreatments, including antibiotics, retinoids, and certain hormone pills,can improve acne, but can have serious adverse effects.

Thus, a need exists for improved methods of treating ocular demodex, anddemodex-induced blepharitis and rosacea. In addition, there is anongoing need for improved treatments for the ocular condition describedas meibomian gland dysfunction and for the dermatological conditions ofacne and rosacea.

SUMMARY OF THE INVENTION

The present invention relates to methods and compositions for treatingocular demodex, demodex-induced blepharitis, meibomian glanddysfunction, acne, and rosacea.

Also disclosed are methods and compositions for treating mange and othermite infestations on a mammalian animal.

The invention inter cilia includes the following, alone or incombination. In one embodiment, the invention relates to a method fortreating ocular demodex or demodex-induced blepharitis in a patient inneed thereof, comprising administrating to the patient a compositioncomprising a therapeutically effective amount of an isoprenoidalessential oil.

Another embodiment of the invention is a method for treating oculardemodex or demodex-induced blepharitis comprising administering to thepatient a composition comprising a therapeutically effective amount of asubstance chosen from at least one of terpinen-4-ol having the formula:

Another embodiment is a method for treating ocular demodex ordemodex-induced blepharitis in a patient in need thereof, comprisingadministrating to the patient a composition comprising a therapeuticallyeffective amount of a substance chosen from at least one ofalpha-Terpineol, Cardinene, d-Carvone, 1-Carvone, gamma-Terpinene,alpha-Terpinene, 1,8-Cineole, alpha-Terpineol, para-Cimene,alpha-Pinene, Limonene, alpha-Thugene, Eucalyptol, (+)-Ledene, CuminicAldehyde, and Myrcene.

Yet another embodiment of the invention is a method for treating adisorder chosen from: rosacea, acne, and meibomian gland dysfunction ina patient in need thereof, comprising: administrating to the patient acomposition comprising a therapeutically effective amount of anisoprenoidal essential oil.

Another embodiment of the invention is a method for treating a disorderchosen from: rosacea, acne, and meibomian gland dysfunction in a patientin need thereof, comprising administrating to the patient a compositioncomprising a therapeutically effective amount of a substance chosen fromat least one of: Terpinen-4-ol, having the formula:

Also disclosed herein is a method for treating a disorder chosen fromrosacea, acne, and meibomian gland dysfunction, in a patient in needthereof, comprising: administrating to the patient a compositioncomprising a therapeutically effective amount of a substance chosen fromat least one of alpha-Terpineol, Cardinene, d-Carvone, 1-Carvone,gamma-Terpinene, alpha-Terpinene, 1,8-Cineole, alpha-Terpineol,para-Cimene, alpha-Pinene, Limonene, alpha-Thugene, Eucalyptol,(+)-Ledene, Cuminic Aldehyde, and Myrcene.

The present invention relates, in one aspect, to a method and a kit forin-office treatment of a disorder chosen from: ocular demodex, oculardemodex-induced blepharitis, rosacea, acne and meibomian glanddysfunction, in a patient in need thereof, comprising: a therapeuticallyeffective amount of a substance chosen from at least one of: anisoprenoidal essential oil, alpha-Terpineol, Cardinene, d-Carvone,1-Carvone, gamma-Terpinene, alpha-Terpinene, 1,8-Cineole,alpha-Terpineol, para-Cimene, alpha-Pinene, Limonene, alpha-Thugene,Eucalyptol, (+)-Ledene, Cuminic Aldehyde, Myrcene, Terpinen-4-ol havingthe formula:

a set of directions for use of the kit for a lid scrub orother method totreat the disorder;

optionally, a plurality of disposable, sterile towels; and

optionally, a dispenser for at least one of the foregoing substances.

In another aspect, the invention relates to a kit for at-home treatmentof a disorder chosen from: ocular demodex, ocular demodex-inducedblepharitis, rosacea, acne, and meibomian gland dysfunction in a patientin need thereof, comprising: a therapeutically effective amount of asubstance chosen from at least one of: an isoprenoidal essential oileffective to treat the disorder, Terpinen-4-ol having the formula:

alpha-Terpineol, Cardinene, d-Carvone, 1-Carvone, gamma-Terpinene,alpha-Terpinene, 1,8-Cineole, alpha-Terpineol, para-Cimene,alpha-Pinene, Limonene, alpha-Thugene, Eucalyptol, (+)-Ledene, CuminicAldehyde, Myrcene, and a shampoo comprising a concentration of at leastone of the foregoing substances effective to treat the disorder; a setof directions for a domestic lid scrub for treating the disorder orother use of the kit to treat the disorder; optionally, a dispenser forat least one of the foregoing substances; optionally, a plurality ofdisposable, sterile towels; and optionally, a squeezable container forholding a facial moisturizer, the container having an opening fordispensing the moisturizer. In one embodiment, the kit includes a set ofdirections for mixing one of the afore-mentioned substances with acommercially available shampoo to prepare a shampoo useful for domesticlid scrub.

Yet another embodiment of the invention is a method for treating aninfestation chosen from sarcoptic mange, demodectic mange, choriopticmange, notoedric mange, and cheyletiella mite infestation on a mammaliananimal, the method comprising administering to the animal in needthereof a therapeutically effective amount of a composition chosen fromat least one of: an isoprenoidal essential oil, Terpinen-4-ol having theformula:

alpha-Terpineol, Cardinene, d-Carvone, 1-Carvone, gamma-Terpinene,alpha-Terpinene, 1,8-Cineole, alpha-Terpineol, para-Cimene,alpha-Pinene, Limonene, alpha-Thugene, Eucalyptol, (+)-Ledene, CuminicAldehyde, and Myrcene.

The invention also relates to a kit for at-home or in-office treatmentof a disorder chosen from sarcoptic mange, demodectic mange, choriopticmange, notoedric mange, and cheyletiella mite infestation on a mammaliananimal in need thereof, comprising: a therapeutically effective amountof a substance chosen from at least one of: an isoprenoidal essentialoil effective to treat the disorder, Terpinen-4-ol having the formula:

alpha-Terpineol, Cardinene, d-Carvone, 1-Carvone, gamma-Terpinene,alpha-Terpinene, 1,8-Cineole, alpha-Terpineol, para-Cimene,alpha-Pinene, Limonene, alpha-Thugene, Eucalyptol, (+)-Ledene, CuminicAldehyde, Myrcene, and a shampoo comprising a concentration of at leastone of the foregoing substances effective to treat the disorder; a setof directions for use of the kit to treat the disorder in the office orat home; optionally, a plurality of disposable, sterile towels; andoptionally, a dispenser for at least one of the foregoing substances. Inone embodiment, the kit includes a set of directions for mixing one ofthe afore-mentioned substances with a commercially available shampoo toprepare a shampoo useful for domestic scrub of the animal in need oftreatment.

The present invention provides important advantages. The methods andeasy-to-use kits according to various embodiments of the inventionfacilitate the eradication of a demodex infestation of the eyelids.Current methods of treating such an infestation, including lid hygieneor washing with ordinary shampoo, that is, one that does not contain anessential oil, reduces demodex counts but does not eradicate demodexinfestation. Our studies have shown that a conventional treatment withdaily lid scrub using Baby Shampoo could not eradicate demodex, possiblybecause ordinary shampoo has no ingredients that can prevent theirpropagation via mating. We have shown that, within one month, weeklyin-office application of Tea Tree Oil dramatically decreased theconcentration of demodex in the patient's eyelid. Eradication of demodexhas not, to our knowledge, been previously achieved by lid hygiene withordinary shampoo alone within twelve months.

BRIEF DESCRIPTION OF THE DRAWINGS

The foregoing and other objects, features and advantages of theinvention will be apparent from the following more particulardescription of illustrative embodiments of the invention, as illustratedin the accompanying drawings in which like reference characters refer tothe same parts throughout the different views. The drawings are notnecessarily to scale, emphasis instead being placed upon illustratingthe principles of the invention.

FIG. 1 represents In Vitro Live and Dead Status of Demodex. The samedemodex was photographed before (FIGS. 1A, C, and E) and 5 min later(FIGS. 1B, D, and F).

FIG. 2 depicts Demodex Counts in Patients Receiving Lid Scrub withDiluted Baby Shampoo.

FIG. 3A through FIG. 3 D depict different results of Lid Scrub with TTOand with Baby Shampoo in a patient presenting with symmetrical signs ofCD in both eyelids.

FIG. 4A through FIG. 4G show migration of Demodex resulting from LidScrub with TTO.

FIG. 5 is a graphical representation of Demodex counts in patientsreceiving Lid Scrub with TTO.

FIG. 6A and FIG. 6B are photographs showing conjunctiva inflamed in botheyes wherein lashes had diffuse CD and high demodex count.

FIG. 6C and FIG. 6D show conjunctiva less inflamed in both eyes afterTTO treatment.

FIGS. 6E and 6F are images produced by kinetic analysis of tearinterference before TTO treatment, images showing persistent crackingstripes in both eyes with uneven lipid tear film.

FIGS. 6G and 6H are images obtained after TTO treatment, the imagesshowing that cracking stripes have disappeared and lipid film is moreevenly distributed.

FIG. 7A through FIG. 7D is a set of photographs showing DR-1 changesbefore and after treatment.

FIG. 8A through FIG. 8F are photographs showing conjunctiva, cornea andDR-1 in the Left Eye before and after TTO Treatment.

DETAILED DESCRIPTION OF THE INVENTION

A description of preferred embodiments of the invention follows. It willbe understood that the particular embodiments of the invention are shownby way of illustration and not as limitations of the invention. At theoutset, the invention is described in its broadest overall aspects, witha more detailed description following. The features and other details ofthe compositions and methods of the invention will be further pointedout in the claims.

The use of Tea Tree Oil in proximity to the eye appears to be previouslyunknown. Although warnings that Tea Tree Oil and other isoprenoidalessential oils should be kept away from the eye are found on MaterialSafety Data Sheets and containers of commercially available samples ofthese oils, we have now discovered a method of using these compositionsto treat ocular demodex, blepharitis, and disorders affecting facialskin, even in areas near the eyes.

Disclosed herein is our discovery that, in 7 out of 9 patients in ourstudy, a combination of both weekly in-office eyelid and lashes scrubwith fifty percent (50%) Tea Tree Oil and at-home daily lid scrub withTea Tree Oil shampoo can eradicate ocular demodex in one month.

Some results of our in vitro and in vivo testing are first summarizedhere, with a detailed description of methods and results provided below.The result of one in vitro killing effect test proved that weekly scrubof TTO is capable of killing demodex within a few minutes, and itskilling effect is concentration-dependent. In order to prove its in vivokilling effect and tolerance, we tested 100% and 50% TTO on patientswith ocular demodex. We achieved the therapeutic effect defined bybringing the demodex counting to zero (0) in five (5) patients in four(4) weeks. The shorter duration of 4 weeks, which is close to one lifecycle of demodex, further suggests that the killing is strong enough toprevent their propagation via mating. In contrast, the conventionaltreatment with daily lid scrub using Baby Shampoo could not killdemodex.

In an attempt to search for a more effective agent to eradicate oculardemodex, a number of known essential oils were tested in vitro. Inaddition to Tea Tree Oil, we found that Caraway Oil and Dill Weed Oilcould each kill demodex within 25 minutes.

In addition to testing the effectiveness of isoprenoidal essential oilsin killing demodex, we isolated and purified many components of theseoils and tested the components, as well as other substances, for use inour disclosed method of treatment.

Disclosed herein is our discovery of an effective method for treatingocular demodex or demodex-induced blepharitis, rosacea, acne, andmeibomian gland dysfunction in patients in need of relief, the methodcomprising: administrating to the patient a composition comprising atherapeutically effective amount of a substance chosen from at least oneof: an isoprenoidal essential oil, such as, for example, Tea Tree Oil,Caraway Oil, Dill Weed Oil and Dill Seed Oil; alpha-Terpineol;Cardinene; d-Carvone; 1-Carvone; (S)-(+)-Carvone hydrate;gamma-Terpinene; alpha-Terpinene; 1,8-Cineole; 1,4-Cineole;alpha-Terpineol; para-Cymene; alpha-Pinene; Limonene, in particular(R)-(+)-Limonene, Dipentene, (+)-cis-Limonene 1,2-epoxide, and(4R)-Limonene 1,2-epoxide, (±)-Limonene oxide, (R)-(—0-Limonene,(S)-(−)-Limonene, and (+)-trans-Limonene 1,2-epoxide; alpha-Thugene;Eucalyptol; (+)-Ledene; S-Terpinolene, Acetaldehyde,3-Isopropoxyphthalide, 3-Propoxyphthalide, Cuminic Aldehyde; andMyrcene, also known as 7-methyl-3-methyleneocta-1,6-diene, furfurol, andcombinations thereof, and pharmaceutically acceptable salts thereof.Each of the foregoing disclosed substances that comprise the compositionare active ingredients.

As the terms are used herein, “active ingredient,” “active agent,” and“therapeutically effective substance” have the same meaning and are usedinterchangeably. Further, the terms “composition of the invention”,“formulation of the invention”, “disclosed composition”, and “disclosedformulation” have the same meaning and are used interchangeably.

The names, structural formulas, molecular formulas, CAS Registrynumbers, boiling points and flash points of different compounds ofessential oils are provided in Table 1. According to one embodiment ofthe invention, an active ingredient of the disclosed composition ischosen from at least one of the compounds listed in Table 1, alone or incombination with other compounds from Table 1.

In another embodiment of the invention, an active ingredient of thedisclosed composition is chosen from at least one of the compoundslisted in Table 1 and at least one essential oil. Any of the variousdisclosed formulations can be included in a kit for in-office treatmentand in a kit for at-home treatment of ocular demodex, demodex-inducedblepharitis, rosacea, acne, and meibomian gland dysfunction. Any of thevarious disclosed formulations can also be included in a kit forin-office treatment and in a kit for at-home treatment of an infestationchosen from sarcoptic mange, demodectic mange, chorioptic mange,notoedric mange, and cheyletiella mite infestation on a mammalian animal

TABLE 1 gamma- Synonyms: Terpinene α-terpinene δ-Terpinolene p-CymeneStructure

Molecular C₁₀H₁₆ C₁₀H₁₆ C₁₀H₁₆ C₁₀H₁₄ Formula Formula 136.23 136.1 136.1134.22 Weight: Registry 99-85-4 99-86-5 586-62-9 99-87-6 number (RN,CAS): Boiling 182° C. 173-175° C. 184-185° C. 176-178° C. point Flashpoint  51° C. Not available Not available     47° C. (4R)- (±)-cis-Limonene Limonene 1,2- (±)-Limonene (R)-(+)- (S)-(−)- Synonyms:1,2-epoxide epoxide oxide, Limonene Limonene Structure

Molecular C₁₀H₁₆O C₁₀H₁₆O C₁₀H₁₆O C₁₀H₁₆ C₁₀H₁₆ Formula Formula 152.23152.23 152.23 136.23 136.23 Weight: Registry 4680-24-4 203719-54-41195-92-2 5989-27-5 5989-54-8 number (RN, CAS): Boiling Not availableNot available 113-114° C./50 175.5-176° C. 175-177° C. point mm Hg3-ISOPROPDXY- 3-PROPDXY- Synonyms: 1-Terpinen-4-ol 1,8-Cineole PHTHALIDEPHTHALIDE Structure

Molecular C₁₀H₁₈O C₁₀H₁₈O C₁₁H₁₂O₃ C₁₁H₁₂O₃ Formula Formula 154.25154.25 192.22 192.22 Weight: Registry 212° C. 176-177° C. Not availableNot available number (RN, CAS): Boiling point 212° C. 176-177° C. Notavailable Not available Flash point  82° C. Not available Not availableNot available Dipentene (S)-(+)- (±)- (S)-(+)- Carvone Synonyms:Limonene 1,4-Cineole (R)-(−)-Carvone Carvone hydrate Structure

Molecular C₁₀H₁₆ C₁₀H₁₈O C₁₀H₁₄O C₁₀H₁₄O C₁₀H₁₆O₂ Formula Formula 136.23154.25 150.22 150.22 168.23 Weight: Registry 138-86-3 470-67-7 6485-40-12244-16-8 60593-11-5 number (RN, CAS): Boiling 170-180° C. Mp: −46° C.227-230° C. 96-98° C./ 157-158° C./ point 10 mm Hg 14 mm Hg (+)-trans-Cuminic Limonene Synonyms: (+)-Ledene Acetaldehyde Furfurol aldehyde,1,2-epoxide Structure

Molecular C₁₅H₂₄ C₂H₄O C₅H₄O₂ C₁₀H₁₂O C₁₀H₁₆O Formula Formula 204.3544.03 98.10 148.20 152.23 Weight: Registry 21747-46-6 75-07-0 98-01-1122-03-2 6909-30-4 number (RN, CAS): Boiling 268-270° C. 22-24° C. 162°C. 235.5° C. Not available point

Components of Caraway Oil: Acetaldehyde, Cuminic Aldehyde, Furfurol,Carvone, Limone

In addition to Tea Tree Oil, other essential oils and compounds listedin Table 1, either alone or in combination, can be added to a shampooand included in a kit for in-office or for at-home treatment of oculardemodex, blepharitis, rosacea, acne, and meibomian gland dysfunction.Alternatively, essential oils and compounds listed in Table 1 can beincluded in the kit along with directions for adding an effectivequantity of the essential oil or compound to a shampoo, water,suspension, gel or powder to produce a formulation for treatment of ahuman or animal. Preferred ingredients are those with higher boilingpoints, because they are less toxic and more effective in killing.

In addition, we have carried out further experiments to show thatTerpinen-4-ol is indeed an active ingredient. (See Table 2 below,Survival Time of Demodex in Different Solutions, which illustrates thedose-dependent relationship of TTO.) Furthermore, we have determinedthat (R)—(+)-Limonene (from Sigma) and Eucalyptol (from Fluka/Sigma) arenot as effective as TTO (See Table 3). However, (+) Carvone is aseffective as TTO (See Table 3).

TABLE 3 Table Killing effect of different agents on Demodex (Time inminutes) (+)-Carvone (+)-Limonene CWO Pilocarpine TTO 100% 50% 25% 97%Eucalyptol 10% 2% 4% (100%) (50%) (25%) 5 8 25 52 30 5 150 150 3 34 30 410 20 67 35 13 150 150 5 30 27 3 11 23 50 40 14 150 150 3 25 5 16 110 4216 150 4 13 55 12 13 Average:   4.2 11.6 22.7 66.8 36.8 12.2 150 150 3.729.7 28.5

As described above, the compositions and methods according toembodiments of the invention can be used on any vertebrate with skin.Examples of such vertebrates include mammals, for example, human,bovine, porcine, canine, feline, and avian.

Methods of Administration

To achieve the improvements described herein, the present inventionprovides for a method of topically administering a disclosed compositionto an affected area of the skin, to the eyelid margin, or to theeyelashes. An affected area of the skin is one which shows symptoms ofthe patient's disorder, symptoms such as, e.g., inflammation, itching,pain, tingling, burning, discoloration, surface irregularities, and/oran erratic accumulation of fibrous tissue. Symptoms may arise from anyof the afore-mentioned disorders, or from a number of types of skintraumas, e.g., laceration, burn, surgery, infection, acne, and chemicalfacial peel. Disclosed compositions of the invention can be administeredin a variety of ways.

In a one embodiment, the compositions of the present invention areadministered by scrubbing an eyelid margin and lashes of the patient, oran affected area of the skin, with the composition. A protocol for thisform of administration is described in detail below. A scrub of theeyelid and lashes or the affected area of the skin with a disclosedcomposition can be accomplished by using a cloth, a sponge, cottonswabs, other applicators, or the fingers. A disclosed composition canalso be administered along with shampoo, in particular, a shampoocomprising at least one active ingredient, such as Tea Tree Oil, anotheressential oil, and a compound listed in Table 1, either alone or incombination with other active ingredients.

In another embodiment, the compositions of the invention areadministered by contacting an eyelid margin and lashes of the patient oran affected area of the skin with the composition, allowing thecomposition to adhere to the eyelid margin and lashes or to the skin,and leaving the composition adhering to the eyelid margin and lashes orto the skin without washing for a period of time sufficient to show animprovement in the condition.

Disclosed variations of the method of contacting the eyelid margin andlashes or the affected area of the skin include smearing or coating thecomposition onto the skin, in the same manner in which one might applyeye liner makeup to the lid margin. We have tested this mode in additionto other modes, and found these methods to be very effective. Othervariations of the disclosed method of application include the use of anapplicator or a squeezable tube filled with the composition. The eyelid,eye lashes, and any affected area of skin on a human or other mammal canalso be scrubbed with an effective amount of one or more of thedisclosed active ingredients.

The administration according to another embodiment is an administrationthat is a combination of two or more routes of administration.

In administering a disclosed composition to an animal other than human,it may be necessary to anesthetize or tranquilize the animal prior toapplying the composition to the face. If anesthesia is necessary, thetreatment can be done in the veterinarian's office.

The in-office treatment of the animal can be followed up with an at-hometreatment of the affected animal by using a disclosed kit comprising atleast one of a shampoo, gel, solution, suspension, or other disclosedformulation according to the instructions included in the kit.Alternatively, the instructions in the kit may include directions forpreparing a formulation such as a shampoo, lotion, or gel for treatingthe animal, the formulation to be prepared from a disclosed activeingredient and water or a commercially available shampoo, lotion orsalve.

While the disclosed methods of treating ocular Demodex orDemodex-induced blepharitis, rosacea, acne, and meibomian glanddysfunction may include administration of one or more of the disclosedsubstances, the substance or combination of substances may also includea physiologically acceptable salt of one or more of the substances. Inone embodiment the substance or combination of substances isadministered in a pharmaceutical composition together with one or moreadjuvants, excipients, carriers and/or diluents.

Therefore, in another embodiment, the present invention also relates topharmaceutical compositions which include a suitable pharmaceuticalcarrier. Any of the disclosed compositions may be administered with asuitable pharmaceutical carrier, the choice of which depends on theroute of administration and the condition of the patient.

The terms “suitable pharmaceutical carrier,” “pharmaceuticallyacceptable carrier,” and grammatical variations thereof, as they referto compositions, carriers, diluents and reagents, are used hereininterchangeably. As the terms are used herein, “suitable pharmaceuticalcarrier” and “pharmaceutically acceptable carrier” refer to non-toxicmaterials that do not interfere with the effectiveness of the biologicalactivity of active ingredients, and represent that the materials arecapable of administration to or upon a vertebrate with a minimum ofundesirable physiological effects such as nausea, dizziness, gastricupset and the like.

The preparation of a pharmacological composition that contains activeingredients dissolved or dispersed therein is well understood in the artand need not be limited based on formulation. Liquid preparationsinclude solutions, suspensions, gels, colloids, hydrogels, andemulsions, for example, water or water-propylene glycol mixtures. Solidforms such as powders suitable for suspending in liquid or gels prior touse can also be prepared. The preparation can also be emulsified.

A disclosed composition can be mixed with excipients that arepharmaceutically acceptable and compatible with the composition, and inamounts suitable for use in the therapeutic methods described herein.Suitable excipients include, for example, water; saline; lubricants suchas corn oil, olive oil, glycerol, petroleum jelly; dextrose; ethanol, orthe like, and combinations thereof.

In one embodiment a disclosed composition for topical administration tothe skin contains a binder such as gum tragacanth, acacia, corn starchor gelatin. Various other materials may be present as coating or tomodify the physical form of the dosage unit.

In addition, if desired, the composition can contain minor amounts ofauxiliary substances such as pH buffering agents and the like whichenhance the effectiveness of the active ingredient or the safety of theadministrative route. Details on techniques for formulation andadministration may be found in the latest edition of Remington'sPharmaceutical Sciences (Maack Publishing Co., Easton, Pa.).

Any of the above formulations and shampoos may be included in a kit forin-office treatment or in a kit for at-home treatment of the patient.Such a kit may also include an applicator for a disclosed formulation.

Therapeutically Effective Amount and Dosage

A disclosed composition is administered to a patient in atherapeutically effective amount. As used herein, the terms“therapeutically effective amount” and “therapeutically effective dose”have the same meaning and refer to the amount of an active agent, forexample, terpinene-4-ol, a therapeutically effective substance, requiredto be administered in order to induce a desired result in the patient.That result may be alleviation or amelioration (complete or partial) ofthe symptoms of the condition of the patient in need of treatment, anyother desired improvement in the patient's symptoms, disease orcondition, or prophylaxis or delay in the onset of symptoms of ocularDemodex or Demodex-induced blepharitis, rosacea, acne, and meibomiangland dysfunction.

The terms “method of treating” or “method for treating” when used inrelation to the present invention means amelioration, prevention orrelief from the symptoms and/or effects associated with a condition inan individual. The person of ordinary skill in the medical artrecognizes that “prevention” of the symptoms and/or effects associatedwith a disease or condition is not an absolute term. In the medical artit is understood to refer to the prophylactic administration of a drugto substantially diminish the likelihood or seriousness of thecondition.

As used herein, the term “therapeutically effective amount” may alsorefer to the quantity of active agent or therapeutically effectivesubstance, such as Terpinen-4-ol, or (+)-Carvone, the administration ofwhich results in improvement in the patient's symptoms, disease, orcondition, where little or no improvement would occur in the absence ofthe active agent. Typically, the therapeutically effective substance isadministered for a sufficient period of time to achieve the desiredtherapeutic effect.

Therapeutic efficacy and the therapeutically effective dose of aparticular substance may be determined by using standard pharmacologicalprocedures in experimental animals and with no more than routine trialsor routine experimentation.

For example, the term “therapeutically effective amount” is intended tomean an amount of a disclosed composition that will alleviate thesymptoms or eradicate Demodex or decrease Demodexin comparison to thelevel prior to administration of the composition. Evaluation of symptomscan be performed using any medically acceptable procedures known tothose of skill in the medical arts.

According to the method of the invention, a disclosed compound can alsobe administered for treating the symptoms of the pathologies associatedwith ocular Demodex or Demodex-induced blepharitis, rosacea, acne, andmeibomian gland dysfunction, or for inhibiting the onset of suchsymptoms.

The dosage regimen of the disclosed compositions is selected inaccordance with a variety of factors including type, species, ageweight, sex and medical condition of the patient; the severity of thecondition to be treated; the route of administration; and the particularcomposition employed. Consideration of these and other relevant factorsare well within the purview of the ordinarily skilled clinician fordetermination of an appropriate therapeutic regimen according to anembodiment of the invention, to attenuate or arrest the progress of thecondition.

Generally, a therapeutic amount of a disclosed compound for use on ahuman or animal is in the range of from about 1 microgram/day to about 1gram/day. This dosage regimen may be adjusted to provide the optimaltherapeutic response.

In embodiments of the above-described methods, the disclosedcompositions may be administered either alone or in combination with oneor more additional bioactive agents, or other therapeutically effectivesubstances. As used herein, the terms “therapeutically effectivesubstance” or “therapeutic substance” include:

-   -   (i) Compounds and compositions recognized in the official United        States Pharmacopoeia, the official Homeopathic Pharmacopoeia of        the United States, or the official National Formulary, or any        supplement of any of them;    -   (ii) Compounds and compositions intended for use in the        diagnosis, cure, mitigation, treatment, or prevention of disease        in man or other animals; and    -   (iii) Compounds and compositions (other than food) intended to        affect the structure or any function of the body of man or other        animals.

A composition disclosed for use in a method according to an embodimentof the invention is intended to include all pharmaceutically acceptablesalt, ester, free acid and lactone forms of the compounds therein whichhave therapeutic activity. Therefore, the use of such salts, esters,free acids and lactone forms are included within the scope of thisinvention.

The invention is described in more detail in the following examples.These examples are provided by way of illustration and are not intendedto limit the invention in any way.

In a preferred embodiment of the invention, in order to eradicatedemodex, the eyelids and lashes of the patient in need of treatmentshould be scrubbed weekly with a composition comprising an isoprenoidalessential oil such as Tea Tree Oil. This in-office treatment should befollowed by twice daily, and then daily at-home eyelid and lashes scrubswith a shampoo containing an isoprenoidal essential oil such as Tea TreeOil. The regimen should continue for a period of time sufficient toeradicate the Demodex infestation. According to one embodiment,disclosed protocols for lid scrubs are as follows.

Weekly In-Office EyeLid and Lashes Scrub:

1. Put about one drop of 0.5% proparacaine into each eye.

2. Dip about 80% of the swab tip (for example, a cotton tipped swab)into the Tea Tree Oil (TTO) so that the swab will not absorb too muchliquid.

3. Make about 6 strokes at the root of the lashes from one end of thelid to the other with a medium (not too hard but not too light)pressure.

4. Use a dry swab to clean the lid margin for one stroke to make surethe excessive solution, if any, will not get into the eye.

5. About five minutes later, clean the dandruffs in the lash root with adry swab with about 5 strokes with a medium pressure. This will removedandruffs which are already loose but still adherent on the lashes as aresult of the first TTO treatment.

6. Wait for approximately another 5 minutes; apply the second TTOtreatment in exactly the same way as Step #2 to #4. Because mites tendto move slowly out under the stimulation of TTO, the subsequent TTOtreatments can cause increased therapeutic effects.

7. After about another 10 minutes, apply the third TTO treatment as Step#2 to #4.

8. The patient should be observed in the office for approximatelyanother 15 minutes to see if there is any irritation. If so, rinse theeye with a non-preserved saline solution, for example, UNISOL®immediately.

9. Repeat the same procedure once every week for 4 weeks, or until thedesired level of improvement or eradication of demodex is achieved.

Domestic (Home) EyeLid and Lashes Scrub:

1. Squeeze 0.5 ml of Tea Tree Shampoo at both middle fingers, mix withwater to generate the shampoo foaming.

2. Close the eyes and massage the Tea Tree shampoo on both eyelids andlashes with a medium pressure for about 3 to about 5 minutes.

3. Rinse the lids and lashes with a lot of clean water.

4. Dry the lids and eyes with clean towel.

5. Apply the procedure twice daily within one month; then apply theprocedure daily.

Other Instructions:

1. Abandon long-used make ups. Wash the hair, the face, nostrils, theexternal ear and neck with Tea Tree shampoo the way you wash the facedaily. Facial cream can be use in a normal fashion, however, take careto not contaminate the face cream. Contamination could occur by, forexample, dipping your fingers into the jar of cream, applying the creamto your face and then dipping the same fingers into the jar again. Inorder to avoid contaminating the cream it is best to put the cream intoan applicator or squeezable container with an opening to dispense thecream, and then squeeze a quantity of the face cream onto your hand.

2. Wash the entire bedding and pillows with hot water or warm dryerimmediately after the first in-office treatment, and then wash themregularly no less than once every week.

3. If your spouse or another family member also notes similar eyeirritation with dandruffs in the lashes, involve him or her in thehygiene described above.

Experimental Study In Vitro and In Vivo Killing of Ocular Demodex by TeaTree Oil Abstract of this Study:

Judging the cessation of body and leg movements, we measured the timeneeded for several agents to kill live adult demodex retrieved fromepilated lashes with cylindrical dandruff. Our result showed thatDemodex folliculorum survived for more than 150 min (no effect) in 10%povidone iodine, 75% alcohol, 50% baby shampoo, 4% pilocarpine,pre-treatment with 50% baby shampoo or 10% SDS followed by 10% povidoneiodine, or pre-treatment with 10% povidone iodine followed by 75%alcohol. However, the survival time was significantly shortened towithin 15 min for 100% alcohol, 100% tea tree oil (TTO), 100% carawayoil, and 100% dill weed oil. TTO's in vitro killing effect wasdose-dependant. A similar result was obtained for Demodex brevis. Lidscrub with 50% TTO, but not with 50% baby shampoo, can stimulate demodexto move out to the skin. The demodex count per 8 lashes did not reachzero in any of the 7 patients receiving daily lid scrub with dilutedbaby shampoo for 40 to 350 days. In contrast, the demodex count droppedto zero in 4 weeks in 7 of 9 patients receiving office lid scrub with50% TTO and home lid scrub with TTO shampoo without recurrence. We thusconclude that demodex is resistant to a wide range of solutions thoughtto be antiseptic. Weekly lid scrub with 50% TTO and daily lid scrub withTTO shampoo is effective in eradicating ocular demodex.

Materials and Methods

Materials

10% povidone iodine, 75% and 100% alcohol, mineral oil, 10% SDS, and TTOwere from Sigma (Milwaukee, Wis., USA), 4% Pilocarpine solution was fromBausch & Lomb (Tampa, Fla., USA), caraway oil and dill weed oil werefrom Essential Oil Company (Portland, Oreg., USA). TT shampoo was fromKato Sales, Inc. (Altamonte Springs, Fla., USA). TTO was diluted withmineral oil into different concentrations.

Statistical Analysis

The data were reported as means±S.D. and analyzed by Microsoft EXCEL®(Microsoft, Redmont Wash.). The data between groups were evaluated bytwo-tailed t test where p<0.05 was considered statistically significant.

In Vitro Killing

Under the microscope, if the epilated lash contained live demodex,different solutions were added to the coverslip edge. The movement ofdemodex body and legs was continuously observed for 150 minutes. Thesurvival time (ST) (Table 2 below) was counted from the time when thesolution was added to the time when the movement ceased (See FIG. 1) Theaverage ST tested for a given solution in a number of mites was used tocompare the in vitro killing effect. If demodex remained alive at theend of 150 minutes, this value was denoted as no effect. Because demodexin an earlier life stage was more vulnerable, we only tested adultdemodex that had 4 pairs of well developed legs and stumpy body. Becausedemodex buried in cylindrical dandruff (CD) might preclude the killingeffect, we only tested demodex of which the whole body was fully exposedto the test solution.

FIG. 1 is a microphotograph showing in vitro Live and Dead Status ofDemodex. The same demodex was photographed before (A, C, and E) and 5min later (B, D, and F). The demodex was judged to be “live” by vividmovement of the body (A, B) or legs (C, D). In contrast, the demodex wasjudged to be “dead” by the lack of movement (E, F). Furthermore, all 8legs of the dead mite were stretched apart (E, F) distinctivelydifferent from the live one (C, D).

TABLE 2 Survival Time of Demodex in Different Solutions Solution 50% BS10% PI 75% Alc MO 4% Pilo Mix 1 Mix 2 Mix 3 ST (min) 150 150 150 150 150150 150 150 DN 9 4 8 5 3 6 5 6 100% 10% 25% 50% 100% 100% 100% SolutionAlc TTO TTO TTO TTO CWO DW0 ST (min) 3.9 ± 1.2 150 34.7 ± 4.3 14.8 ± 9.53.7 ± 0.8 4.4 ± 2.3 14.0-18.3 DN 7 5 5 11 21 16 5 [Note]: ST: survivaltime recorded in minute, DN: number of demodex tested, BS: baby shampoo,MO: mineral oil, PI: povidone iodine, Alc: alcohol, Mix 1: 50% BS inwater for 30 min followed by 10% PI, Mix 2: 10% SDS in water for 30 minfollowed by 10% PI, and Mix 3: 10% PI for 30 min followed by 75% Alc,TTO: tea tree oil. CWO: caraway oil, DWO: dill weed oil and Pilo:pilocarpine.Results: In Vitro Killing Effect

We first surveyed a number of agents listed in Table 2 (above), andnoted that 50% baby shampoo, 100% mineral oil, 75% alcohol, 10% povidoneiodine, or 4% Pilocarpine could not kill demodex in 150 minutes. Incontrast, 100% alcohol killed it in 3.9±1.2 minutes. Because demodex isfrequently trapped in the CD, which consists of cellular debris made oflipids and keratins (English F P, Nutting W B. Demodicosis of ophthalmicconcern. Am. J. Ophthahnol. 1981; 91:362-72.), we also examined whethera pretreatment with such a detergent as 10% SDS or 50% baby shampoomight promote the killing effect of other agents. The results showedthat none of such pre-treatments for 30 minutes could facilitate thekilling by subsequent application of either 10% povidone iodine or 75%alcohol. In contrast, 100% of TTO, caraway oil or dill weed oil killedmites in 3.7±0.8, 4.4±2.3, and 14.0±8.3 minutes, respectively.Furthermore, the killing effect of TTO was dose-dependent, i.e., being14.8±9.5, 34.7±4.3, and 150 minutes for 50%, 25% and 10% of TTO,respectively (p<0.01). These results indicated that 100% TTO, 50% TTO,100% caraway oil and 100% dill weed oil exerted effective in vitrokilling within 15 minutes. 50% TTO and 10% TTO also exerted a similarkilling of D. brevis (not shown).

In Vivo Studies—Patients

This study followed the Tenets of Helsinki Declaration of Human. Allpatients had received routine complete eye examination and externalphotography, and found to have ocular demodex (see below). They were notusing topical or systemic anti-inflammatory and anti-bacterialmedications. Seven patients had practiced eyelid scrub with diluted babyshampoo at least once daily. Nine patients received lid scrub with TTOin the office and daily eyelid and lashes scrub with Tea Tree Oilshampoo (TT shampoo) at home. As the term is used herein, “lid scrub”refers to scrubbing of both eyelid and eyelashes.

Lash Sampling and Demodex Counting

For each patient, we epilated a total of 8 lashes with CD, two from eacheyelid, and covered them with a coverslip on a slide. Under themicroscope, if the lash did not retain CD, BSS was added; if itcontained CD, 100% alcohol was added to the edge of the coverslip todissolve CD. The total number of demodex counted from these 8 lashes wasused for comparison.

Lid Scrub with TTO

In the office, after a drop of 0.5% proparacaine was instilled to eacheye, a cotton tip dipped in 50% TTO was used to scrub the lash rootsfrom one end to the other of an eyelid with a medium pressure, countedas one stroke. A total of 6 strokes were applied to each lid. A drycotton tip was then used to remove excess TTO from the lid margin.Because TTO scrub not only loosened CD but also stimulated demodex tomove out to the skin (see Results), a dry cotton tip was used to removeCD 5 minutes later. After another 5 minutes, the second lid scrub withTTO was applied in the same manner. After 10 minutes of rest, the thirdTTO lid scrub was applied. If there was any irritation, the eye wasrinsed with non-preserved saline.

Home Lid Scrub and Other Instructions

At home, the patient was asked to mix 0.5 ml of TT shampoo with tapwater in both middle fingers. With eyes closed, the eyelids and lasheswere massaged with a medium pressure for 3 to 5 minutes. The skin wasthen rinsed with clean water and dried with a towel. Such at home lidscrub was practiced twice daily for one month and then once dailythereafter. In addition, the patient was also instructed to discard usedfacial make-ups, and wash the hair, the face, nostrils, the external earand the neck with TT shampoo daily. The bedding and pillow cases werewashed with hot water and dried in a heated dryer immediately after thefirst office scrub, and once a week thereafter. If the spouse alsocomplained of similar eye irritation, the same at home lid scrub wasalso practiced.

In Vivo Killing by Lid Scrub with Diluted Baby Shampoo

FIG. 2 depicts Demodex Counts in Patients Receiving Lid Scrub by DilutedBaby Shampoo. In these 7 patients, their serial demodex counts did notdrop to zero despite daily lid scrub with diluted baby shampoo whenpracticed for more than one month.

Cases #3, #4, and #5 maintained a constant number of demodex after 40 to350 days of lid hygiene. Case #1 and #7 actually showed an increase ofdemodex after 110 to 350 days. Only Case #2 and #6 showed a decrease ofdemodex after 64 and 125 days of lid hygiene, respectively, but neverreached zero.

In Vivo Killing by Lid Scrub with TTO

We recently confirmed that lashes with cylindrical dandruff (CD) ispathognomonic for ocular demodex. It is thus important to get rid of CD,which harbors demodex. Studies show that lid hygiene with shampooreduces demodex counts but does not eradicate demodex Lid hygiene withshampoo cleans only CD extending outside the skin, but does noteradicate demodex buried deep under the skin. See Y. Y. Gao et al.,Invest Ophthalmol V is Sci. 2005 September; 46 (9):3089-94, theteachings of which are incorporated herein by reference in its entirety.Applicants have developed a more effective therapy, not by solelycleansing but rather by killing demodex buried deep in the follicle.

In a patient presenting with symmetrical signs of CD in both eyelids,lid scrub with 50% TTO in the right eye and with 50% baby shampoo in theleft eye for 5 min equally cleaned off CD (FIGS. 3A and 3B). However,demodex was found on the skin surface adjacent to the lashes (FIG. 3C,arrows), and demodex tail was seen protruding from the lash root (FIG.3C, arrowheads) in the TTO treated eye, but not in the baby shampootreated eye (FIG. 3D). Furthermore, the skin in the eye receiving TTOwas redder than that receiving baby shampoo. These findings suggestedthat lid scrub with TTO did not merely mechanically remove CD from thelash root, but might attract mites to move out to the skin.

To examine this possibility, we epilated lashes with diffuse CD (FIG.4A) and found that D. folliculorum clustered around the lash follicle(FIG. 4D). After office lid scrub with 50% TTO, the lashes were free ofCD (FIG. 4B). Interestingly, tails were protruding from the lash root(FIG. 4B, arrow). When these lashes were epilated, D. folliculorum wasfound on the lash trunk close to the skin surface, i.e., away from thelash follicle (FIG. 4E). When such lash was rotated by a forceps beforeepilation, we noted several mites migrating along the lash trunk (FIGS.4F and 4G). If no home lid scrub was subsequently practiced, CD returnedin one week (FIG. 4C). If the lashes were scrubbed with baby shampoo,simple mechanical rotation did not stimulate demodex to move out (notshown). These results indicated that lid scrub with 50% TTO, but notbaby shampoo, indeed stimulated demodex to migrate from CD embeddedinside the skin.

Because lid scrub with 50% TTO did not kill mites buried deep in theskin, and because if no lid scrub was carried out at home, CD quicklyreturned in one week, we advocated that weekly office lid scrub with 50%TTO be followed by daily home eyelid and lash scrub with TT shampoo in 9patients (FIG. 5). The results showed that the demodex count dropped tozero in 3 weeks in 5 patients and in 4 weeks in another 2 patientswithout any recurrence one month later. These 7 patients were younger(59.86±8.7 year-old), and had a mean count of 7.9±4.1 before treatment.In the remaining 2 patients, Case No. 1 and Case No. 2, the count didn'treach zero, and showed a rebound 35 days and 14 days after treatment,respectively. They were a 68 year old patient and an 81 year-oldpatient, and had a higher count of 26 and 16, respectively, beforetreatment. The rebound count was less than the previous one, and theinterval between rebounds was 2 to 3 weeks.

Discussion

In this report, we were surprised to note that the demodex count of all7 patients receiving daily lid hygiene with baby shampoo never reachedzero in a period between 40 and 350 days, i.e., beyond one life cycle(FIG. 2). This result together with those published earlier (Junk A K,et. al. “Topical administration of metronidazole gel as an effectivetherapy alternative in chronic Demodex blepharitis—a case report,”Klin.Monatsbl.Augenheilkd. 213:48-50; (1998); Fulk G W, et. al.,“Pilocarpine gel for the treatment of demodicosis—a case series,”Optom.Vis.Sci. 73:742-5 (1996)) strongly imply that this conventionaltreatment cannot eradicate demodex, a notion also confirmed by thefinding that 50% baby shampoo did not kill demodex in vitro (Table 2).We were also surprised to note that 75% alcohol and 10% povidone iodine,agents known to kill most microbes, could not kill demodex in vitro(Table 2). Because prior incubation with 50% baby shampoo or 10% SDS,detergents dissolving oil, before 10% povidone iodine still could notkill demodex (Table 2), we believe that the body surface of demodex isresistant to povidone iodine.

Although 4% Pilocarpine gel was used to treat demodex, it did not killdemodex in 150 min (Table 2). In 1970, Norn (Norn M S., Demodexfolliculorum. Incidence and possible pathogenic role in the humaneyelid, Acta Ophthalmol Suppl 1970; 108:7-85.) tested 45 differentagents and found only few could kill demodex within several minutes.They are absolute alcohol, ether, xylol, benzene, Danish(sulfur-containing) ointment, organophosphate-cholinesterase inhibitors,dill weed oil, and caraway oil. Consistent with his finding, we notedthat 100% alcohol did kill demodex within 3.9±1.2 minutes. Furthermore,100% of dill weed oil and caraway oil, both being nature essential oils,also killed demodex in 14±8.3 and 4.4±2.3 min, respectively (Table 2).Unfortunately, these agents are not amenable for clinical uses becausetheir intrinsic toxicity and irritation to the eye.

We were encouraged by TTO's killing effect, which resembled that ofcaraway oil and exhibited a clear dose-dependent relationship (Table 2).Although the killing effect of TTO on lice is thought to be mediated byanti-cholinesterase activity (Mills C, et al. Inhibition ofacetylcholinesterase by Tea Tree oil, J. Pharm.Pharmacol, 2004;56:375-9), it cannot explain its killing effect on nits or demodex.Although TTO might cause contact dermatitis and allergy (Simpson E L,et. al., Prevalence of botanical extract allergy in patients withcontact dermatitis, Dermatitis 2004; 15:67-72.), TTO shampoo iscommercially available for treating head lice without an adverse effect.The dermal LD50 in rabbits exceeds 5 g/kg, and undiluted TTO does notproduce phototoxic effects on the skin of hairless mice (Ford R A, et.al., Monographs on fragrance raw materials, Food Chem.Toxico, 1988;26:273-415.). TTO patch test does not cause adverse reactions (Brenan JA, et al., Evaluation of patch testing in patients with chronic vulvarsymptoms, Australas.J.Dermatol., 1996; 37:40-3.).

It is taught that Tea Tree Oil should be kept away from the eyes.Because of the historic warnings to keep Tea Tree Oil away from the eye,there was no obvious way to use Tea Tree Oil to treat ocular demodex,However, even though we had no reasonable expectation of success, wedecided to try to develop a method of using TTO to treat ocular demodex.

Although both effectively cleaned CD from the lashes, TTO, but not babyshampoo, stimulated demodex to migrate from the CD buried inside of theskin (FIG. 3 and FIG. 4). However, if daily lid scrub were not followed,CD returned in one week (FIG. 4).

FIG. 3 shows different results of Lid Scrub by TTO and Baby Shampoo. Ina patient presenting with symmetrical signs of CD in both eyelids, lidscrub was performed in the office by 50% TTO in the right eye (A) and by50% baby shampoo in the left eye (B). In either eye, CD was clean afterscrub (C, D), however, demodex could be found on the lid margin adjacentto the lashes (C, arrows), and demodex tail could be visualizedprotruding from the lash root (C, arrowheads) after TTO scrub. Thesefindings were not detected in the eye after baby shampoo scrub althoughthe skin surface was less red (D).

FIG. 4 shows migration of Demodex by Lid Scrub with TTO. In this eyewith diffuse CD found in the lashes before treatment (A), epilation ofthe lash (marked by arrow) showed a fragment of CD attached to the lashand abundant demodex embedded close to the lash follicle (D). Afteroffice eyelid and lashes scrub with 50% TTO, the lashes became clean,and totally free of CD, but tails of demodex were protruding from thelash roots (B, arrow). Three minutes after eyelid and lashes scrub, freedemodex was found on the trunk close to the skin surface, i.e., awayfrom the lash follicle in the epilated lash (E). Rotating these lashes(shown in B) before epilation allowed us to detect a group of demodexmigrating along the lash trunk (F and G). If no eyelid and lashes scrubwas carried out at home for one week, CD returned to the lashes one weeklater (C).

Because mechanical agitation to the lash following TTO scrub wassufficient to stimulate demodex to migrate out to the skin, we advocatedaily eyelid and lashes scrub with TT shampoo following each office lidscrub with TTO. Because neither 50% baby shampoo nor TT shampoo, ofwhich the concentration of TTO is less than 10%, could kill demodex invitro (Table 2), we believe that home eyelid and lashes scrub acts byarousing demodex to move out and eliminating them before demodex matingoccurs. Although D. brevis is also found in lash samples (Ford R A, et.al., Monographs on fragrance raw materials, Food Chem.Toxicol, 1988;26:273-415), it is not mentioned in demodex related blepharitis (EnglishF P, et. al., Demodicosis of ophthalmic concern, Am. J. Ophthalmol.,1981; 91:362-72.).

Herein, D. brevis was found in patients with blepharitis and exhibitedsimilar susceptibility to TTO killing in vitro.

Using the proposed scrub regimen with TTO and TT shampoo, the demodexcount was dramatically reduced in one week and reached zero in one monthwithout recurrence in 7 of 9 patients (FIG. 5). The two patients thatfailed to be eradicated were older, started with a higher demodex count,and rebound in an interval of 2 to 3 weeks. Norn (Supra) and our recentstudies (manuscript submitted) have noted that patients with a higherdemodex count tend to be older, suggesting that demodex infestation, ifuntreated, tends to be worsened with age due to continuous propagationby mating. We thus speculate that higher demodex infestation producesmore CD inside and outside the lash follicle, and more resistant to TTO.If this interpretation were correct, we predict that it is easier totreat demodex at an early stage. Alternatively, the failure might becaused by re-infestation by mites migrating from other places of thebody or from the spouse. Because the rebound count was less than theprevious one, we speculate that continuing the eyelid and lashes scrubregimen might eventually eradicate demodex.

Now that ocular demodex can be eradicated by eyelid and lashes scrubwith TTO, we can begin to investigate its pathogenic role in generatingsymptoms of irritation, signs of inflammation, and disturbance of thelipid tear film in the future.

“Clinical treatment of ocular demodex results in the eradication ofdemodex”, Y. Y. Gao, et al., Br J Ophthalmol., 2005 November;89(11):1468-73, is incorporated herein by reference in its entirety. Theclinical study analyzed the outcome of treating ocular demodecosis bylid scrub with Tea Tree Oil. The study included 11 patients with oculardemodex who received weekly eyelid and lashes scrub with 50% TTOcombined with daily lid hygiene (lid and lashes scrub) with tea treeshampoo. After TTO lid and lashes scrub, the demodex count dropped tozero in less than 4 weeks in 8 of 11 patients. Ten of the 11 patientsshowed different degrees of relief of symptoms and notable reduction ofinflammatory signs. Vision improved in 6 of 22 eyes and the lipid spreadtime was significantly shortened without a change in the lipid filmthickness. Demodex potentially causes ocular surface inflammation,meibomian gland dysfunction and lash abnormalities. Eyelid and lashesscrub with TTO can effectively eradicate ocular demodex and result insubjective and objective improvements. Nine patients (Cases No. 1 to No.9) underwent the kinetic analysis of tear interference images before andafter TTO eyelid and lashes scrub.

After TTO lid scrub, all patients were free of CD. In these 11 patientswho received weekly TTO lid scrub plus daily lid scrub with tea treeshampoo, the demodex counts dropped sharply in the first week after TTOtreatment for all patients. The demodex counts dropped to zero in 3weeks for 6 patients, and in 4 weeks in another 2 patients, and didn'tdrop to zero in 5 to 9 weeks in 3 patients (Table 4). After weeklyoffice lid scrub with 50% TTO and daily home lid scrub with TTO shampoo,9 of 11 patients experienced 50% to 100% improvement in symptoms.

TABLE 4 Uncorrected Conjunctival Allergy Complaints Vision inflammationCase Age Sex Diagnosis history Before After Before After Before After 168 F Recurrent No Redness, 80%, 20/200 Same +++ + pterygium, lash FBS,redness 20/200 loss itching for 100%, 2 years FBS, itching, more opening2 81 M Suspicious No Pain, 60%, all 20/20 Same +++ + cicatricialtearing, symptoms 20/80 pemphigoid, burning for MGD, Cch, 4 yearstrichiasis, lash loss, multiple glaucoma surgeries 3 55 F MGD, Cch, NoFBS, 100%, all 20/20 Same + − trichiasis chronic symptoms 20/20irritation for 5 years 4 68 M Recurrent No None 80%, less 20/40 20/25 −− pterygium, weight in 20/25 20/25 trichiasis, lash lids, more lossopening, see better 5 70 M MGD, lash loss, No Persistent 100%, 20/2520/25 +++ − suspicious redness, pain 20/70 20/25 cicatricial blurry 70%,pemphigoid, vision for redness cornea epithelial 10 years, defect painfor 1 year 6 44 M MGD, LASIK Pollen, mold, dust Persistent 75%, 20/20Same ++ + dry eye mite redness, redness, 20/20 dryness, dryness, itchingfor 100%, 3 years itching 7 63 F MGD, Cch, NA Dryness, 90%, all 20/30Same ++ − conjunctivitis itching for symptoms 20/20 5 years 8 60 MConjunctivitis, NA FBS, 100%, 20/50 Same ++ + trichiasis, dryness, FBS,20/40 punctuate grittiness dryness keratopathy for 2 years 50%,grittiness 9 59 M MGD, Pollen, mold, dust Persistent 85%, all 20/40 Same++ + conjunctivitis mite redness, symptoms 20/40 dryness for 8 years 1042 F MGD, No Pain, FBS 100%, all 20/30 20/25 − − conjunctivitis for 10days symptoms 20/25 20/20 11 52 M Conjunctivitis, No None None 20/2520/20 − − trichiasis 20/25 20/20 MGD: Meibomian gland dysfunction; Cch:Conjunctivochalasis; FBS: Foreign body sensation; LTD: Lipid teardeficiency; NA: Not available; Vision: upper line is for the right eye,lower line is for the left eye.

The clinical data support that ocular demodex infestation causesabnormalities in the ocular surface, lash follicles and meibomianglands.

One common manifestation of ocular demodex infestation is ocular surfaceinflammation. Eight of 11 patients showed conjunctival injection andamong them 8 had an underlying disease that is known to be associatedwith conjunctival inflammation. To provide stronger evidence that ocularsurface inflammation might be resulted from demodex infestation, changeswere recorded after lid scrub with TTO. Lashes with CD were better andmore effectively cleaned by lid scrub with 50% TTO than baby shampoo.After lid scrub with TTO, conjunctival inflammation was markedly reducedand the ocular surface and facial temperatures were also significantlyreduced. In light of the fact that their prior inflammation was notcontrolled by anti-inflammatory medications in 8 cases and systemicimmunosuppression in one case, we strongly suspect that demodex, if notcausatively linked with, aggravates the existing inflammation.

Accompanied with the reduction of ocular surface inflammation wasnotable reduction of symptoms in 9 patients that presented with priorannoying irritation (Table 5). In addition to causing ocular surfaceinflammation, demodex might cause damage in the lash follicle asevidenced by the loss of lashes in 4 and intermittent trichiasis in 5 of11 patients.

TABLE 5 Demodex Counts After Treatment. Case CD at lashes 0 week 1 week2 week 3 week 4 week 5 week 6 week 7 week 8 week 9 week 1 Diffuse 26 125 3 0 11 8 2 4 2 2 Diffuse 16 2 4 8 3 4 3 Sporadic 5 1 0 0 4 Diffuse 133 3 1 0 0 5 Sporadic 6 1 2 0 0 6 Sporadic 3 1 0 0 7 Diffuse 14 1 10 2 00 8 Sporadic 8 4 0 0 9 Sporadic 6 1 0 0 10 Sporadic 7 2 11 5 2 3 2 11Diffuse 16 7 0 0

Fourthly, demodex might cause damage in the meibomian gland leading toan abnormal lipid tear film as revealed by the kinetic analysis of tearinterference images (Table 6).

TABLE 6 Kinetic Analysis of Tear Interference Images Before and AfterTTO Treatment Lipid Pattern Lipid Spread Time Lipid Thickness Case OD OSOD OS OD OS Before TTO 1 v v 1.93 2.32 70 60 2 m m 2.12 1.73 100 70 3 mm 2.7 1.54 50 60 4 m m 1.74 3.09 90 70 5 v m 1.74 1.54 70 50 6 m m 1.931.54 80 60 7 m m 2.31 2.31 60 70 8 m m 1.73 1.54 80 50 9 v m 1.93 1.9380 60 Mean 2.01 1.95 75.6 61.1 SD 0.32 0.53 15.1 7.82 After TTO 1 m m1.37 1.73 90 80 2 m m 1.16 1.35 80 70 3 m m 1.16 0.97 60 60 4 m m 1.541.35 70 80 5 m m 0.77 1.16 70 60 6 h m 1.16 1.16 80 80 7 m m 1.16 2.3140 40 8 m h 1.35 1.35 70 60 9 m m 1.16 1.35 80 70 Mean 1.20 1.41 71.166.7 SD 0.21 0.39 14.5 13.2 T Test 0.0003 0.012 0.38 0.30 Lipid pattern:h: horizontal wavy; v: vertically streaking; m: mixed.

All 9 patients subjected to kinetic analyses of tear interference imagesshowed Lipid Tear deficiency (LTD) dry eye. This finding supports theexistence of meibomian gland dysfunction, presumably caused by either CDand debris from demodex that might have destabilized the lipid tear filmor interfered with the meibum lipid formation.

Because TTO treatment led to a significant improvement in the spreadtime in the lipid tear film, resulting in an overall much more stableand even tear film, resolution of corneal epithelial abnormalities insome cases, and an improved visual acuity in others (Table 6), TTO lidscrub may have dissolved the keratinized plug in the meibomian glandorifice and facilitated the lipid expression. Furthermore, TTO lid scrubstimulates demodex to move out and might kill most, if not all, ofdemodex inside meibomian gland, and improve its function. Cleansing ofdemodex might also alter bacterial flora and load, which indirectly mayalso improve symptoms, inflammation or meibum lipid composition.Confirmation of demodex's pathogenicity relies on a treatment with anagent such as TTO that can eradicate demodex.

Following are nine clinical examples (Cases 1 through 9).

CLINICAL EXAMPLES Case Example No. 1

A 68 year-old female complained of foreign body sensation, redness anditching in the left eye for 2 years. On Feb. 4, 2004, she receivedsurgery to remove primary pterygium and reconstruction with amnioticmembrane transplantation. The pterygium recurred on May 4, 2004, and shereceived another pterygium removal and reconstruction with conjunctivalautograft from the right eye. Nevertheless, the pterygium recurredshortly afterwards, and she was referred to Ocular Surface Center forbeing considered for re-operation for her multi-recurrent pterygium. OnJul. 7, 2004, besides recurrent pterygium, she was found to havemeibomian gland dysfunction, conjunctivochalasis, and aqueous tear andlipid tear deficiency dry eye. Furthermore, her lashes were loaded withdiffuse cylindrical dandruff (CD). The diagnosis of ocular demodicosiswas made because of a high demodex count of 19 per 8 lashes (i.e., 19demodex mites found in a total of 8 lashes in two eyes). Lid hygiene,i.e., lid scrub with shampoo, was advised, but she did not notice anyimprovement 3 weeks later (Jul. 28, 2004). Therefore, non-preserved 0.2%dexamethasone was prescribed three times a day, both eyes, for 1 weekwith tapering for another week. She returned on Oct. 13, 2004 with lessredness but her lashes were still coated with CD with a demodex count of19. Therefore, her lid margins were coated with 50% Tea Tree Oil (TTO)for one time without lid scrub on Oct. 13, 2004. On Oct. 18, 2004, herlashes still presented with similar CD and the demodex count was 26. Theabove data indicated that both baby shampoo lid scrub and coating thelashes with 50% TTO could not eradicate ocular demodex. Because wesubsequently found out that although 50% TTO can kill demodex in14.8±9.5 min in vitro, it can stimulate demodex to move out of thelashes in vivo {described in separated paper}, we started office lidscrub recipe as described above on this patient on this visit. One weeklater she present with sporadic CD with the demodex count dropping to12. Her symptoms decreased and her eyes could open with more comfort.Four weeks later, the demodex count dropped to 0, but rebounded to 11.Since then we had continued the same weakly office scrub and daily homescrub for a total of 9 weeks during which time the demodex countsrebounded 2 times and the final demodex count was 2. At the final visit,she presented with clean lashes, her conjunctiva was less red, and hersymptoms improved 80% to the extent that her daily life was notdisturbed. Interestingly, her inflamed recurrent pterygium becamenon-inflamed to the point that no surgery was contemplated. Beforetreatment, the kinetic analysis of tear interference images by DR-1showed a vertical pattern in both eyes, the lipid spread time of 1.93sec and 2.32 sec, and the lipid thickness of 70 nm and 60 nm in theright eye and left eye. Respectively. After treatment, the lipid spreadtime was shortened to 1.37 sec and 1.73 sec and the lipid thickness was90 nm and 80 nm in right eye and left eye, respectively.

The method and apparatus for kinetic analysis of tear interferenceimages by DR-1 is described in detail in U.S. patent application Ser.No. 10/131,665 by Tseng and Goto, the teachings of which areincorporated herein by reference in their entirety.

Case Example No. 2

An 81 year-old male complained of dryness in the left eye worse than theright eye and chronic irritation for the past 4 years. His left eyereceived 6 times of glaucoma drainage implant surgeries for primary openangle glaucoma. On 11/11/02, he was referred to Ocular Surface Centerand was found to have exposure keratopathy due to ectropion, misdirectedlashes, cicatricial keratoconjunctivitis (thought to be due to oldtrachoma), meibomian gland dysfunction with lipid tear deficient (LTD)dry eye, and delayed tear clearance in both eyes. His conjunctiva wasinflamed. His left eye was treated with non-preserved 1%methylprednisolone drops, and then with symblepharonlysis, formixreconstruction, intraoperative application of mitomycin C, and amnioticmembrane transplantation on Jan. 17, 2003. He also receivedsubconjunctival injection of long-acting steroid (Keralog®) in the lefteye on Jan. 7, 2003 and horizontal lid tightening of both lower lids onMay 15, 2003 for ectropion. Despite all these procedures, he continuedto complain of dryness, tearing, burning and fluctuating blurry vision.On Nov. 10, 2004, his conjunctiva was inflamed in both eyes (FIGS. 7Aand 7B). His lashes had diffuse CD and the demodex count was 16. All theocular medications were stopped. He received office TTO lid scrub andhome lid scrub. Lashes became clean, and demodex count was 2, 4, 8, 3, 4at the ensuring weekly follow up visit. His conjunctiva became lessinflamed in both eyes (FIGS. 7C and 7D), his symptoms were 60% relieved,and his vision improved 1 line in the right eye and 2 lines in the lefteye. The kinetic analysis of tear interference images by DR-1 showed amixed pattern in both eyes before and after treatment. The lipid spreadtime was 2.12 and 1.73 sec before and 1.16 and 1.35 sec after treatment,lipid thickness was 100 nm and 70 nm before, and 80 and 70 nm aftertreatment in right eye and left eye, respectively. Before treatment,DR-1 showed persistent cracking stripes at the inferior cornea in botheyes with uneven lipid tear film (FIGS. 7E and 7F). After treatment, thecracking stripes disappeared and the lipid film became more evenlydistributed (FIGS. 7G and 7H).

FIG. 7 shows conjunctiva and DR-1 changes before and after TTOtreatment. Both bulbar and tarsal conjunctivae were red in the right eye(7A) and the left eye (7B) before TTO treatment. They became lessinflamed after TTO treatment (7C, and 7D, respectively). DR-1 showed anuneven distribution of the lipid tear film and persistent crackingstripes on the inferior cornea of the right eye (7E) and the left eye(7F). These changes disappeared and the lipid film became more evenlydistributed after treatment (7G and 7H).

Case Example No. 3

A 55 year-old female complained of foreign body sensation and irritationin the left eye worse than the right eye for 5 years. She receivedbilateral upper lid blepharoplasty in 1998, and surgical excision ofconjunctival cysts for 3 times, epilation of trichiasis, and insertionof punctual plugs in 2002. Because of persistent foreign body sensationand chronic irritation, she was referred to Ocular Surface Center andfound on Jul. 17, 2002 to have trichiasis (2 on the left upper lid),meibomian gland dysfunction, and lipid tear deficient dry eye. Shereceived 0.2% non-preserved dexamethasone eye drops, epilation,subconjunctival injection of long-acting steroid (KERALOG®). On Aug. 12,2004, she received excision of conjunctivochalasis and reconstructionwith amniotic membrane transplantation in the left eye, and wore abandage contact lens postoperatively. Despite these treatments, shecontinued to complain of these symptoms. On Nov. 15, 2004, her lasheswere found to have sporadic CD, and the demodex count was 5. Shereceived lid scrub with 50% TTO and home lid scrub with TT shampoo. Thedemodex count dropped to 1 on Nov. 22, 2004, and 0 on Nov. 29, 2004, andher lashes were free of CD. During the ensuing one month, the demodexcount remained 0 without rebound. One surprising founding was thattrichiasis did not recur during the two months of follow up. Her eyescould open more comfortable without any foreign body sensation andirritation. The DR-1 pattern was mixed in both eyes before and aftertreatment. The lipid spread time dropped from 2.7 sec and 1.54 sec to1.16 sec and 0.97 sec in the right eye and the left eye, respectivelyafter treatment. The lipid thickness was 50 nm and 60 nm before and 60nm and 60 nm in right eye and left eye, respectively.

Case Example No. 4

This 68 year-old male presented to Ocular Surface Center on Oct. 7, 2002for the management of primary pterygium in his right eye. Interestingly,he had been suffering from misdirected lashes due to an unknown cause inthe left eye worse than the right eye for more than 20 years, to whichhe received weekly epilation by his wife. He received removal ofpterygium and reconstruction with amniotic membrane transplantation onFeb. 13, 2003. Although he felt fine after surgery, conjunctival rednesspersisted and became more obvious on Jun. 2, 2003, i.e., 4 months aftersurgery. He also complained of foreign body sensation and itching. Ninemonths after surgery, recurrent pterygium was noted and surgery wasperformed on Jan. 9, 2004 with intraoperative application of mitomycin Cand reconstruction with amniotic membrane transplantation. After thesecond surgery he felt some foreign body sensation, which disappeared 4months after surgery. He returned for a routine check up on Dec. 1, 2004without obvious discomfort, but her lashes had diffuse CD, right eyeworse than left eye. The demodex count was 13. He received the treatmenton Dec. 1, 2004. One week later, he felt “less weight” in the eyelid,could see better, and noted that he was less bothered by misdirectedlashes. In the following week, he declared that it required epilatedevery 5 days in the past, but now felt fine without it for more than 14days after epilation. The demodex count dropped to 3, 3, 1, and 0 in theensuing weekly follow up after treatment. Her vision improved one linein the right eye and 4 lines in the left eye. Before treatment, DR-1showed that the lipid tear film was colorful, unevenly distributed withnumerous granules in the right eye and a persistent cracking patches inthe inferior cornea of the left eye. After treatment, DR-1 showed a moreevenly distributed lipid film without granules or cracking patches. Thelipid spread time was shortened in both eyes despite the fact that thelipid tear film thickness decreased in the right eye.

FIG. 8A through 8D is a set of photographs showing DR-1 changes beforeand after treatment. Before treatment, the lipid film was colorful andunevenly distributed with many granules in the right eye (8A) andpersistent cracking patch predominantly at the inferior cornea in theleft eye (8B). After treatment the lipid film became more evenlydistributed with less granules (8C) and did not have any crackingpatches in the left eye (8D).

Case Example No. 5

This 70 year old optometrist complained of persistent redness and blurryvision in the left eye and misdirected lashes in both eyes for more than10 years. He was initially diagnosed ocular cicatricial pemphigoid andwas treated with Dapsone and topical Lotemax in 2001 without relief. Hisconjunctival redness was worse in the morning upon awakening. He wasfirst seen at Ocular Surface Center on Jun. 16, 2003 to have cicatricialkeratoconjunctivitis, conjunctivochalasis, trichiasis, meibomian glanddysfunction, floppy eye lids, and delayed tear clearance. He was askedto stop Lotemax and Dapsone and strarted with oral Cyclophosphamide 50mg tid. However, his symptoms didn't diminish even though hesubsequently received multiple epilation, Restasis, 0.2% non-preserveddexamethosone, artificial tears, and subconjunctival injection ofKERALOG at different visits. He received symblepharon lysis, removal ofconjunctivochalasis, intraoperative application of mitomycin, andreconstruction with amniotic membrane in the right eye on Dec. 19, 2003,and the same procedure on Jan. 23, 2004 in the left eye. Although theseprocedures made him feel better for several months, conjunctival rednesspersisted and ocular irritation returned 4 months later. On Aug. 2,2004, he was noted to have superficial corneal erosion with pain andirritation in the left eye. Although soft contact lens made him feelfree of pain and irritation, the corneal lesion persisted. He wasinserted with a punctal plug in the left lower lid on Aug. 2, 2004 foraqueous tear deficient dry eye, but did not notice improvement. On Dec.15, 2004, his lashes were noted to have CD and the demodex count was 6.Thus he began office scrub with TTO and home scrub with TTO shampoo, andhis topical medication was limited to artificial tears only.Surprisingly, on the next visit his eye irritation was relieved, rednessdecreased and his vision improved from 20/70 to 20/25. Although he losthis contact lens after the first TTO treatment, he did not note any painin the left eye. The demodex count dropped to 0 after 2 weeks oftreatment without recurrence.

Before the treatment, there was redness on the forehead, cheeks, nose,chin and eyelid, which was dramatically decreased after treatment, itwas conformed by the infrared picture. From FIG. 9. we can see infraredpicture, conjunctiva injection, cornea lesion and DR-1 at left eyedramatically changed at the time initiated the treatment and the timedemodex dropped to 0.

Infrared thermographs show changes in the Left Eye before and after TTOTreatment. Infrared thermographs (not presented here to preserve patientconfidentiality) show diffuse redness on the whole face including theupper and lower lids before treatment, and less redness after treatment.FIGS. 9A through 9F are photographs showing conjunctiva, cornea and DR-1in the Left Eye before and after TTO Treatment. The bulbar conjunctivawas red before treatment (9A), and was less red after treatment (9B).The cornea showed an irregular epithelium before treatment (9C), whichdisappeared after treatment (9D). DR-1 showed that the lipid film wascolorful, uneven and had cracking stripes around the corneal lesionbefore treatment (9E), but became more even and free of these crackingstripes after treatment (9F).

EQUIVALENTS

While this invention has been particularly shown and described withreferences to preferred embodiments thereof, it will be understood bythose skilled in the art that various changes in form and details may bemade therein without departing from the scope of the inventionencompassed by the appended claims.

What is claimed is:
 1. A cleaning device comprising (a) a sterile towel;and (b) a solution consisting essentially of terpinen-4-ol as an activeagent and one or more pharmaceutically-acceptable excipients, whereinthe solution does not include tea tree oil.
 2. The cleaning device ofclaim 1, wherein the one or more pharmaceutically-acceptable excipientsare selected from water, saline, corn oil, olive oil, glycerol,petroleum jelly, dextrose, ethanol, or a combination thereof.
 3. Thecleaning device of claim 1 wherein the one or morepharmaceutically-acceptable excipients is water, glycerol or acombination thereof.
 4. The cleaning device of claim 1, wherein theterpinen-4-ol is present in an amount effective to treat a Demodexinfection in a subject in need thereof.
 5. The cleaning device of claim4, wherein the amount of terpinen-4-ol effective to treat a Demodexinfection in a subject in need thereof is between about 1 microgram/dayto about 1 gram/day.
 6. The cleaning device of claim 5, wherein theDemodex infection is an ocular Demodex infestation or Demodex-inducedblepharitis.
 7. A method of cleaning the skin of an individual,comprising contacting the skin of the individual with the cleaningdevice of claim
 1. 8. The method of claim 7, wherein contacting the skinof the individual with the cleaning device comprises scrubbing the skinwith the cleaning device.
 9. The method of claim 7, wherein contactingthe skin of the individual with the cleaning device comprises washingthe skin with the cleaning device.
 10. The method of claim 7, whereinthe skin comprises a face, eye, eyelid, eyelid margin, eyelash, eyelashroots or a combination thereof.
 11. The method of claim 7, wherein thecleaning device further comprises one or morepharmaceutically-acceptable excipients.
 12. The method of claim 11,wherein the one or more pharmaceutically-acceptable excipients areselected from water, saline, corn oil, olive oil, glycerol, petroleumjelly, dextrose, ethanol, or a combination thereof.
 13. The method ofclaim 11, wherein the one or more pharmaceutically-acceptable excipientscomprise water, glycerol or a combination thereof.
 14. The method ofclaim 7, comprising contacting the skin of the individual with thecleaning device for at least 4 weeks.
 15. The method of claim 7,comprising contacting the skin of the individual with the cleaningdevice daily.
 16. The method of claim 7, comprising contacting the skinof the individual with the cleaning device twice daily.
 17. The methodof claim 7, comprising contacting the skin of the individual with thecleaning device weekly.
 18. The method of claim 7, wherein thetherapeutically effective amount of terpinen-4-ol is between about 1microgram/day to about 1 gram/day.
 19. The method of claim 7, whereinsaid cleaning comprises treating an ocular Demodex infestation orDemodex-induced blepharitis in the individual.
 20. The method of claim7, wherein the individual is refractory to an anti-inflammatory,conventionally anti-microbial antibiotic, or an anti-allergy therapy forocular Demodex infestation or Demodex-induced blepharitis.